Form Ftb 9109 - Cooperative Membership printable pdf download

STATE OF CALIFORNIA

FRANCHISE TAX BOARD

HOMEOWNER AND RENTER ASSISTANCE PROGRAM

PO BOX 942886

SACRAMENTO CA 94286-0940

COOPERATIVE MEMBERSHIP

This is to certify that the claimant named below owned one or more units/apartments in a cooperative. The claimant’s

share of property taxes on these cooperative units/apartments is stated below:

FIRST NAME

MIDDLE INITIAL

LAST NAME

SOCIAL SECURITY NUMBER

DID THE CLAIMANT OWN THIS PROPERTY ON DECEMBER 31 IMMEDIATELY PRECEDING THE CLAIM YEAR?

UNIT OR APARTMENT NUMBER

YES

NAME OF COOPERATIVE

STREET ADDRESS

CITY

STATE

ZIP CODE

CALIFORNIA

PROPERTY TAX

Line 1 – Enter total net value of property as shown on tax bill that includes claimant’s unit/apartment (after homeowner

or veterans exemption).

Line 2 – Enter claimant’s percentage of ownership in property. (Divide square footage of claimant’s unit/apartment by

square footage of all units/apartments covered by property tax bill.)

Line 3 – Enter net assessed value of claimant’s unit/apartment. (Multiply total net value shown on line 1 by the percent-

age on line 2.)

Line 4 – Enter claimant’s property tax. (1 percent of figure shown on line 3.)

Please complete the following:

1. Full net value of the property (after Homeowners or Veterans Exemption) . . . . . . . . . . . . . .

$ ________________

2. Claimant’s percentage of ownership in the property . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

______________ %

3. Net assessed value of claimant’s unit/apartment (line 1 x line 2) . . . . . . . . . . . . . . . . . . . . .

$ ________________

4. Claimant’s property tax (1 percent of net value) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

$ ________________

SIGNATURE OF COOPERATIVE OFFICER

TITLE

DATE

For privacy information get the Franchise Tax Board Privacy Notice, form FTB 1131.

ATTACH THIS FORM TO YOUR

HOMEOWNER ASSISTANCE CLAIM.

TELEPHONE AND INTERNET ASSISTANCE

You can hear pre-recorded answers to many of your Homeowner and Renter Assistance questions, order claim forms, or check the status of your

assistance payment in English and Spanish. Please have paper and pencil ready to take notes.

From within the United States, call . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (800) 868-4171

From outside the United States, call (not toll-free) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (916) 845-6600

Website at:

Assistance for persons with disabilities: We comply with the Americans with Disabilities Act. Persons with hearing or speech impairments, please call

TTY/TDD (800) 822-6268.

FTB 9109 (REV 08-2004)

Form Ftb 9109 - Cooperative Membership

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